Latissimus Dorsi Tendon Transfer Research Articles

Lower Trapezius and Latissimus Dorsi Transfer relieve Teres Minor Activity into the Physiological Range in Collin D Irreparable Posterosuperior Massive Rotator Cuff Tears: A Biomechanical Analysis

Tendon transfers are established techniques to regain external rotation mobility in patients suffering from an irreparable, posterosuperior massive rotator cuff tear (MRCT). Posterosuperior MRCT with intact teres minor (Type D MRCT) can lead to excessive teres minor loading to maintain external rotation. We hypothesize that tendon transfers are effective in relieving teres minor loading in Type D MRCTs. Our aim was to biomechanically assess muscle synergism with latissimus dorsi (LD-Transfer) and lower trapezius (LT-Transfer) tendon transfer during external rotation at different abduction heights. Using musculoskeletal modeling, we analyzed and compared the moment arm, muscle torque and muscle activity between a healthy and Type D MRCT pathological model with and without the LD- or LT-Transfer at infraspinatus and teres minor insertion sites. Output measures were analyzed during external rotation at different abduction angles and 10 to 50N resistance against external rotation. We assessed its impact on teres minor loading in a Type D MRCT. Morphological variations were parameterized using the critical shoulder angle and the acromiohumeral distance to address variations among patients. Both transfer types reduced teres minor torque and activity significantly, reaching physiological state at 40N external resistance (p<0.001), with insertion to infraspinatus site being more effective than teres minor site (p<0.001). External rotation moment arms of LD-Transfer were larger than LT-Transfer at 90° abduction (25.1±0.8mm vs. 21.2±0.6mm, p<0.001) and vice versa at 0° abduction (17.4±0.5mm vs. 24.0±0.2mm, p<0.001). While the healthy infraspinatus was the main external rotator in all abduction angles (50-70% torque), a Type D MRCT resulted in a 70-90% increase of teres minor torque and an up to sevenfold increase in its activity leading to excessive loadings beyond 10N resistance against external rotation. Varying the critical shoulder angle and the acromiohumeral distance led to minor variations in muscle moment arm and muscle activity. We identified biomechanical efficacy of both tendon transfers in Type D MRCT regarding teres minor load relieve and superior performance of the transfers at the infraspinatus insertion site.

Intraoperative repair of functional subscapularis during RSA by deltopectoral approach could improve internal rotation but does not prevent anterior dislocation

IntroductionThe role of the subscapularis following reverse shoulder arthroplasty (RSA) remains controversial as repair could restore adequate internal rotation and shoulder stability, but might compromise external rotation. The purpose of this multi-centre study, on a large cohort of RSAs performed using the deltopectoral approach, was to determine the effect of subscapularis preoperative status and intraoperative repair on range of motion, clinical scores and rates of complications at a minimum follow-up of 2 years. HypothesisRepair of a functional subscapularis grants better internal rotation and stability without compromising external rotation. Materials and methodsWe retrospectively reviewed records of all RSAs (n=916) performed by 14 surgeons that participated in a large national society symposium, and excluded 234 operated by the anterosuperior approach, 42 operated for rheumatoid arthritis, fractures, instability or post traumatic sequalae, and eight that had adjuvant latissimus dorsi tendon transfer (LDTT). This left 632 RSAs, in which the subscapularis was detached in 594, and repaired after detachment in 495. Patients completed pre- and postoperative Constant Score and postoperative Subjective Shoulder Value (SSV). Active forward elevation, active external rotation (ER), and active internal rotation (IR) were recorded pre- and postoperatively. Complications following RSA that required conservative treatment, reoperation without implant removal, as well as reoperation with implant removal were recorded. ResultsOf the initial cohort of 632 shoulders, 120 (19%) were lost to follow-up, 12 (2%) died due to causes unrelated to RSA, and 26 (4%) were revised with implant removal. Of the remaining 474 shoulders, 259 (55%) had a functional repaired subscapularis (Group FR), 59 (12%) had a non-functional repaired subscapularis (Group nFR), whereas 68 (14%) had a not repaired subscapularis (Group nR). Comparison of patient demographics revealed no significant differences among the three groups. Postoperative Constant Score (p=0.031) and SSV (p=0.016) were significantly different among the three groups, but effect sizes were small and not clinically relevant. Differences in postoperative ER as well as postoperative IR were not significant among the three groups: 91 (35%) gained functional IR in Group FR, 11 (19%) in Group nFR, and 13 (19%) in Group nR. Three shoulders (1.2%) reported subjective instability and 1 (0.4%) dislocated in Group FR, but none in either Groups nFR or nR. DiscussionDespite statistically significant differences in Constant Score and SSV among the three groups, the clinical relevance of these differences is negligible, so repair of functional subscapularis has little or no influence on functional outcomes. During RSA by deltopectoral approach, repair of a functional subscapularis could slightly improve internal rotation in some patients but does not compromise external rotation, forward elevation or clinical scores, while repair of a non-functional subscapularis, compared to non-repair, did not improve range of motion or clinical scores. Level of evidenceIII; retrospective comparative.

Combined Anterior Latissimus Dorsi and Teres Major Tendon Transfer (aLDTM) for Irreparable Anterosuperior Rotator Cuff Tears.

Transfer of the anterior latissimus dorsi and teres major (LDTM) tendons has demonstrated favorable outcomes in patients with irreparable anterosuperior rotator cuff tears1. The objective of this procedure is to restore internal rotation strength, enhance active range of motion, and provide pain relief while preserving the glenohumeral joint. The incision extended from the coracoid to the inferior border of the pectoralis major tendon, following the deltopectoral interval located laterally to the coracoid. While preserving the pectoralis major tendon, the latissimus dorsi (LD) and teres major (TM) tendons are identified and detached from the humerus without separating the tendons. The LDTM tendons are grasped, and nonabsorbable sutures are placed in a continuous running-locking suture fashion. Traction is applied to the sutures while bluntly releasing the adhesions surrounding the LDTM muscles in order to enable further mobilization and excursion. With the patient's arm positioned in full internal rotation and at 45° of abduction for physiological tensioning, the LDTM tendons are attached 2 cm distal to the lateral edge of the greater tuberosity and lateral to the biceps groove with use of 1 medial anchor and 3 lateral anchors. Arthroscopic partial repair, superior capsular reconstruction, pectoralis major tendon transfer, and isolated LD tendon transfer are potential alternative treatments. In cases in which these options are not feasible or have been unsuccessful, reverse total shoulder arthroplasty can be considered as a treatment option. Arthroscopic partial repair can provide pain relief, but its effectiveness in improving range of motion and muscle strength is limited2,3. Additionally, there is a high risk of retear, with reported rates as high as 52%4. Superior capsular reconstruction is considered a viable treatment, but it is not recommended in cases involving irreparable subscapularis tears5-7. Pectoralis major transfer may lead to less favorable clinical outcomes in cases in which an irreparable subscapularis tear and an irreparable supraspinatus tear are simultaneously present8-10. In cases of irreparable anterosuperior rotator cuff tears, the transfer of the LD tendon alone may not fully restore the superior migration and anterior subluxation of the humeral head.11. Reverse total shoulder arthroplasty may be another option in these cases, but it does not preserve the glenohumeral joint. The procedure involves stabilizing the superior translation of the humeral head by rebalancing the force couple, as the TM tendon exhibits scapulohumeral kinematics similar to the subscapularis tendon. Additionally, the procedure effectively reduces anterior glenohumeral subluxation through the combined effect of the posterior line of pull from the combined LDTM tendons and the scapulohumeral kinematics of the teres minor tendon. Also, by fixing the transferred LDTM tendons just distal to the greater tuberosity, the vector becomes less vertical, thereby preventing axillary nerve impingement and achieving appropriate tendon tensioning. The use of this procedure is supported by a study of 30 patients who were followed for a minimum of 2 years1. Significant improvements were observed in various scoring systems, including the pain VAS (visual analogue scale), Constant, ASES (American Shoulder and Elbow Surgeons), UCLA (University of California-Los Angeles), SANE (Single Assessment Numeric Evaluation), and ADLIR (Activities of Daily Living requiring active Internal Rotation) scores. Importantly, there was no significant progression of cuff tear arthropathy observed during the final follow-up. Additionally, preoperative anterior glenohumeral subluxation (15 of 30 patients) was restored in all patients after LDTM tendon transfer. Careful attention should be paid to the anterior humeral circumflex vessels to prevent bleeding.The radial nerve, passing through the anteroinferior surface of the LDTM tendons, should be carefully identified and protected to avoid iatrogenic injury.To maintain physiologic tension, the patient's arm should be positioned in full internal rotation and 45° of abduction.To avoid axillary nerve impingement, the LDTM tendons should be fixed just distal to the greater tuberosity and lateral to the biceps groove. SCR = superior capsular reconstructionLDTM = latissimus dorsi combined with teres majorASRCTs = anterosuperior rotator cuff tearsA/S = arthroscopicROM = range of motionTM = teres majorTm = teres minorLD = latissimus dorsiSSC = subscapularisSSP = supraspinatusPM = Pectoralis majorPm = Pectoralis minorRSA = reverse total shoulder arthroplastyASES = American Shoulder and Elbow SurgeonsUCLA = University of California-Los AngelesADLIR = Activities of Daily Living requiring active Internal RotationGT = greater tuberosityACR = anterior capsular reconstructionFF = forward flexionER = external rotationIR = internal rotationAHD = acromiohumeral distanceMRI = magnetic resonance imagingISP = infraspinatusPEEK = polyetheretherketonePOD = postoperative dayEMG = electromyographySD = standard deviationBMI = body mass indexDM = diabetes mellitusHTN = hypertensionVAS = visual analogue scaleSANE = Single Assessment Numeric EvaluationaROM =active range of motion.

Irreparable Subscapularis Tears: Current Tendon Transfer Options.

Irreparable subscapularis tears, especially in younger patients with higher functional demands, present a challenging entity. Pectoralis major and latissimus dorsi tendon transfers are commonly considered for surgical management of this pathology, yet no consensus exists regarding the superior option. The purpose of this article is to review the most current tendon transfer techniques for irreparable subscapularis tears. For decades, transfer of the pectoralis major has been considered the gold standard technique for irreparable subscapularis tears. This transfer was found to reduce pain and improve functional outcome scores, yet range of motion and force of internal rotation were not maintained in long-term follow-up studies. The latissimus dorsi tendon transfer for the same indications has demonstrated biomechanical superiority in recent cadaveric studies with promising short-term results clinically. Both pectoralis major and latissimus dorsi tendon transfers improve outcomes of patients with irreparable subscapularis tears. Future comparative studies are still needed to determine superiority amongst techniques.

Surgical management for massive rotator cuff tears: a network meta-analysis of randomized controlled trials.

Multiple surgical strategies have been developed for treating massive rotator cuff tears (mRCTs). However, there is still no consensus on the best surgical option for mRCTs. Through a network meta-analysis, we aimed to comprehensively and systematically analyse the evidence in randomized controlled trials to help clinicians make evidence-based clinical decisions for patients with mRCTs. Our study was a network meta-analysis of the surgical management of mRCTs (PROSPERO Registration ID: CRD42023397971). We searched PubMed, EMBASE, Cochrane and Web of Science for randomized controlled trials that examined the efficacy of surgical management for mRCTs up to 3 November 2022. A three-step method was employed for the study process. Study selection, data extraction and risk of bias evaluation were conducted by two independent reviewers. R software (version 4.2.1) and Stata (version 15.1) were used for the data analysis. From 10,633 publications, we included 15 randomized controlled trials (996 participants) for the quantitative analysis. In terms of both long-term and short-term surgical effects, there were no statistically significant differences among surgical interventions such as patch-augmented rotator cuff repair (RCR), RCR with platelet-rich plasma, arthroscopic decompression, bridging reconstruction, arthroscopic RCR with platelet-leukocyte membrane, open RCR, mini-open RCR, arthroscopic debridement, superior capsular reconstruction, arthroscopic suture-spanning augmented repair, subacromial balloon spacer and latissimus dorsi tendon transfer. Based on algorithms, the probability ranking suggests that patch augmentation is the most highly ranked surgical intervention for achieving better short-term surgical outcomes. Furthermore, arthroscopic-associated mini-open RCR was ranked as the highest surgical intervention for achieving better long-term surgical effects. Based on the available data from the included studies, similar surgical efficacies were observed among the reported intervention measures for mRCTs. The patch augmentation technique was found to potentially achieve better short-term surgical outcomes, which is consistent with previous reports. However, the best surgical interventions for achieving long-term surgical effects remain unknown. More high-quality research is needed to evaluate the efficacy and safety of these interventions and to guide clinical practice.

Changes in in vivo three dimensional shoulder kinematics following latissimus dorsi tendon transfer for irreparable posterosuperior rotator cuff tears: A systematic review with meta-analysis

BackgroundLatissimus dorsi transfer is a surgical procedure that can be used for treating posterosuperior rotator cuff tears. The procedure leads to improved shoulder function via alterations in the force vector couple around the shoulder. However, there is still no consensus on the biomechanical changes resulting from latissimus dorsi transfer. MethodsWe performed a systematic review of the literature on 3D motion analysis studies evaluating the effects of latissimus dorsi transfer on shoulder kinematics. The available data on segment and joint range of motion was extracted and subject to meta-analysis when consistent across the studies. FindingsOur meta-analysis of pre- and post-operative studies revealed a significant improvement in forward flexion and abduction following latissimus dorsi transfer. When comparing the latissimus transferred shoulder with an uninjured contralateral side the meta-analysis found no significant difference in flexion range of motion, while abduction and external rotation was significantly higher in the uninjured shoulders. The overall risk of bias was moderate to high. High heterogeneity was found in the reporting of data, which limited our ability to perform a meta-analysis across the studies for all interest outcomes. InterpretationsOur findings suggest that latissimus dorsi transfer for posterosuperior rotator cuff tears effectively improves shoulder flexion and abduction. External rotation is also expected to improve but at inferior levels as compared to the unaffected side. However, the heterogeneity of the reported data on 3D motion analysis studies highlights the need for better standardization in research and reporting as to conclude the impact of different joints.

The Role of Early Latissimus Dorsi Tendon Transfers for Shoulder Movement and Stability in Neonatal Brachial Plexus Injury

The Role of Early Latissimus Dorsi Tendon Transfers for Shoulder Movement and Stability in Neonatal Brachial Plexus Injury

Full arthroscopic vs. arthroscopically assisted posterosuperior latissimus dorsi tendon transfer for shoulders with failed and irreparable rotator cuff repair: matched case-control study

To compare clinical outcomes and complication rates of full arthroscopic latissimus dorsi tendon transfer (LDTT) vs. arthroscopically assisted LDTT, for the treatment of irreparable posterosuperior massive rotator cuff tears (mRCTs) in shoulders that had failed rotator cuff repair (RCR). We evaluated a continuous series of 191 patients who underwent LDTT over 4 consecutive years. A total of 107 patients did not have previous shoulder surgery, leaving 84 patients who had prior surgical procedures. All procedures performed over the first 2 years were arthroscopically assisted (n=48), whereas all procedures performed over the last 2 years were full arthroscopic (n=36). We noted all complications, as well as clinical scores and range of motion at ≥24 months. To enable direct comparison between the 2 techniques, propensity score matching was used to obtain 2 groups with equivalent age, sex, and follow-up. Compared with the 48 patients who underwent arthroscopically assisted LDTT, the 36 patients who underwent full arthroscopic LDTT had comparable complications (13% vs. 11%) and conversions to RSA (8.3% vs. 5.6%). Propensity score matching resulted in 2 groups, each comprising 31 patients, which had similar outcomes in terms of clinical scores (except mobility component of Constant score, which was better following fully arthroscopic LDTT; P=.037) and range of motion at a minimum follow-up of 2years. At a minimum follow-up of 24 months, for the treatment of irreparable posterosuperior mRCTs in shoulders that had surgical antecedents, full arthroscopic LDTT had significantly better mobility component of the Constant score than arthroscopically assisted LDTT, although there were no significant differences in the other clinical or functional outcomes. Arthroscopically assisted LDTT and full arthroscopic LDTT had comparable rates of complications (8.3% vs. 13%) and conversion to RSA (5.6% vs. 8.3%).

Physiotherapy outcomes following latissimus dorsi tendon transfer in a patient with massive rotator cuff tear: a case report

This study aims to evaluate the early-term rehabilitation outcomes of a 63-year-old female patient who under went latissimus dorsi transfer following a massive rotator cuff tear. Rotator cufftearstypically occur in individuals over middle age due to degenerative causes, while in younger individuals and athletes, they can be a result of trauma. These tears can lead to symptoms such as pain, muscleweakness, and limitedrange of motion. While conservative treatments are generally effective, surgical intervention may be necessary in some cases. Latissimus dorsi tendon transfer is a surgical procedure used to restore active external rotation of the shoulder in massive tears. This method provides an alternative treatment option. This study presents the early-term rehabilitation outcomes of the patient.

Modified Arthroscopic Latissimus Dorsi Transfer at the Infraspinatus Footprint With Anterior Extracortical Fixation

Massive irreparable cuff tears may represent as many as 20% to 40% of total cases of operated rotator cuff tears and can be a challenging clinical problem. Many treatment options have been proposed for their treatment. Among these options, latissimus dorsi tendon transfer can be considered a good alternative, especially in young patients before they develop glenohumeral arthritic changes. This technique aims at rebalancing the shoulder with a functioning subscapularis muscle and restoring both active external rotation and elevation with the aid of a properly functioning deltoid muscle. The modified arthroscopic latissimus dorsi transfer at the infraspinatus footprint with anterior extracortical fixation rebalances the pair of forces acting on the shoulder, stabilizing it in the transverse plane, minimizing the risk of latissimus dorsi transferred rupture and associated complications.

Outcomes of Reverse Total Shoulder Arthroplasty with Latissimus Dorsi Tendon Transfer for External Rotation Deficit

Background: Latissimus dorsi transfer (LDT) has been purported to restore motion in patients undergoing reverse shoulder arthroplasty (RSA) who have preoperative combined loss of forward elevation (FE) and external rotation (ER). This systematic review summarizes the available evidence for the functional outcomes and complications after RSA with LDT. Furthermore, the effect of implant design and whether a concomitant teres major transfer (TMT) was performed were studied. Methods: A systematic review was performed per Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We queried PubMed/MEDLINE, Embase, Web of Science, and Cochrane databases to identify articles reporting on LDT with RSA to restore ER. Our primary outcomes were ER, FE, Constant score, and complication incidence. Secondarily, we reported postoperative internal rotation (IR) and compared ER, FE, and Constant score based on lateralized versus medialized global implant design and whether concomitant TMT was performed. Results: Nineteen studies were evaluated; functional outcomes were assessed in 16 articles reporting on 258 RSAs (123 LDT, 135 LDT-TMT). Surgical indication was most commonly cuff tear arthropathy and massive irreparable cuff tear. Mean ER was −12° preoperatively and 25° postoperatively, FE was 72° preoperatively and 141° postoperatively. Mean postoperative Constant score was 65. Of 138 patients (8 studies) describing IR, only 25% reported a mean postoperative IR ≥L3. Subanalysis comparing lateralized versus medialized implants and whether TMT was concomitantly performed demonstrated no significant difference in postoperative ER, FE, and Constant score, nor preoperative to postoperative improvement in ER and FE. The complication rate was 14.1% (of 291 shoulders from 16 studies), including tear in the tendon transfer (n = 3), revision tendon repair (n = 1), nerve-related complication (n = 9), and dislocation (n = 9). Conclusions: RSA with LDT is a reliable option to restore motion, with a comparable complication rate with standard RSA. The use of medialized versus lateralized implants and whether the TM was concomitantly transferred may not influence clinical outcomes. Level of Evidence: Level IV. See Instructions for Authors for a complete description of levels of evidence.

Superior Capsular Reconstruction Versus Latissimus Dorsi Tendon Transfer for Irreparable Rotator Cuff Tears: Minimum 5-year Outcomes.

Arthroscopic superior capsular reconstruction (SCR) has been introduced as a successful alternative to latissimus dorsi tendon transfer (LDTT) for irreparable posterosuperior rotator cuff tears. To compare minimum 5-year clinical outcomes of SCR and LDTT for the treatment of irreparable posterosuperior rotator cuff tears in patients with minimal evidence of arthritis and intact or reparable subscapularis tears. Cohort study; Level of evidence, 3. Patients who underwent SCR or LDTT and had undergone surgery ≥5 years earlier were included. The SCR technique used a dermal allograft customized to the defect. Surgical, demographic, and subjective data were collected prospectively and reviewed retrospectively. Patient-reported outcome (PRO) scores utilized were the American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), the short version of the Disabilities of the Arm, Shoulder and Hand score (QuickDASH), 12-Item Short Form Health Survey Physical Component Summary (SF-12 PCS), and patient satisfaction. Further surgical procedures were documented, and treatment that progressed to reverse total shoulder arthroplasty (RTSA) or revision rotator cuff surgery was considered a failure. Kaplan-Meier survivorship analysis was performed. Thirty patients (n = 20 men; n = 10 women) with a mean follow-up of 6.3 years (range, 5-10.5 years) were included. A total of 13 patients underwent SCR and 17 patients underwent LDTT. The mean age of the SCR group was 56 years (range, 41.2-63.9 years), and the mean age of the LDTT group was 49 years (range, 34.7-57 years) (P = .006). One patient in the SCR group and 2 patients in the LDTT group progressed to RTSA. Two additional (11.8%) patients in the LDTT group had further surgery-1 had arthroscopic cuff repair and 1 had hardware removal with biopsies. The SCR group demonstrated significantly better ASES (94.1 ± 6.3 vs 72.3 ± 16.4; P = .001), SANE (85.6 ± 8 vs 48.7 ± 19.4; P = .001), QuickDASH (8.8 ± 8.7 vs 24.3 ± 16.5; P = .012), and SF-12 PCS (56.1 ± 2.3 vs 46.5 ± 6; P = .001) PROs at the final follow-up. There was no significant difference between groups in median satisfaction (SCR, 9; LDTT, 8 [P = .379]). At 5 years, survivorship rates were 91.7% and 81.3% for the SCR and LDTT groups, respectively (P = .421). At the final follow-up, SCR yielded superior PROs compared with LDTT for the treatment of massive, irreparable posterosuperior rotator cuff tears despite similar patient satisfaction and survivorship between procedures.

Concomitant latissimus dorsi tendon transfer during reverse total shoulder arthroplasty does not improve active external rotation or clinical outcomes in patients with external rotation deficit.

To assess the role of latissimus dorsi tendon transfer (LDT) concomitant with reverse total shoulder arthroplasty in patients with external rotation (ER) deficit secondary to severe rotator cuff deficiency with and without glenohumeral arthritis. Patients with a positive external lag sign and <10° of active external rotation (aER) treated with reverse shoulder arthroplasty at a single institution with a minimum 12-month follow-up were retrospectively identified from a prospective database. Basic demographic information along with preoperative and postoperative range of motion (ROM) measures, American Shoulder and Elbow Surgeons score (ASES), Visual Analog Scale (VAS) pain, and Subjective Shoulder Value scores were obtained. Statistical analysis was performed to compare ROM and functional outcomes between patients who underwent concomitant LDT and those with no transfer (NT). The LDT (n=31) and NT (n=33) groups had similar age, sex distributions, and follow-up length average (24 vs. 30months). No differences were found between groups at baseline, final follow-up, or magnitude of change for ASES, VAS pain, and Subjective Shoulder Value scores. Baseline ROM measures were similar, except for the LDT group having slightly less aER (-8° vs. 0°; P=.004). In addition, all postoperative ROM measures including aER were similar, except for a slight improvement in active internal rotation in the NT group. The majority of patients were satisfied with their outcome (LDT 84% (n=26); NT 87% (n=27); P=.72). Patients with ER deficit secondary to severe rotator cuff deficiency with and without glenohumeral arthritis undergoing reverse total shoulder arthroplasty do not have significantly improved ER or patient-reported outcome measures with LDT.

Latissimus Dorsi and Teres major tendon transfer increases internal rotation torque following lateralized reverse shoulder arthroplasty with subscapularis insufficiency.

Limitation of active Internal Rotation (IR) following Reverse Shoulder Arthroplasty (RSA) in patients with massive Rotator Cuff Tears (mRCTs) with subscapularis insufficiency remains a challenge. Recently, RSA with Latissimus dorsi and Teres major (LDTM) transfer in patients with limited active IR has been demonstrated as a reliable treatment option. The purpose of this study was to biomechanically compare the IR torque following LDTM transfer with RSA in mRCT with subscapularis insufficiency to RSA without tendon transfer. Eight cadaveric shoulders were tested (mean age: 64.5 ± 1.9years) using a custom shoulder testing system that permits loading conditions of mRCT with subscapularis insufficiency. Two conditions were tested and compared. The first condition was RSA alone and the second condition was RSA with LDTM transfer. RSA with a medialized glenoid and lateralized humerus design was used for all specimens. The specimens were tested at 0°, 20° and 40° abduction at three different muscle loads: baseline, double, and triple, while the Teres minor and deltoid loads were kept constant. IR torque was measured with a torque wrench at 0°, 20°, and 40° abduction and 60° and 45° IR positions. Force required for anterior dislocation was measured at 20° abduction and 10° IR position. RSA with LDTM transfer had significantly higher IR torque at all abductions and muscle loading compared with RSA without transfer (average at all positions; RSA without transfer: 0.80 ± 0.02 Nm, LDTM transfer for all loads: 1.43 ± 0.10 Nm). RSA with LDTM transfer (91.4 ± 3.9 N) needed higher force for anterior dislocation compared to RSA alone (89.4 ± 4.1 N), but there was no significant difference. LDTM transfer with RSA increases IR torque compared to RSA without tendon transfer in a cadaveric model. LDTM transfer with RSA may be a reliable treatment option for patients with mRCT and subscapularis insufficiency who are expected to have limited active IR following RSA.

Biomechanical comparison of combined latissimus dorsi and teres major tendon transfer vs. latissimus dorsi tendon transfer in shoulders with irreparable anterosuperior rotator cuff tears.

Irreparable anterosuperior rotator cuff tears (IASRCTs) can result in a gradual loss of active elevation and internal rotation, superior and anterior translation of the humeral head, and cuff tear arthropathy. Joint-preserving treatment options for IASRCTs in young and high-demand elderly patients remain a subject of ongoing debate. The aim of the study was to evaluate the biomechanical efficacy of the combined latissimus dorsi and teres major tendon (LDTM) transfer and compare it to an isolated latissimus dorsi (LD) transfer in a cadaveric IASRCT model. Eight cadaveric shoulders (mean age, 68.3±5.2 years; range 58-71) were tested with a custom shoulder testing system. All specimens were tested at 0°, 30°, and 60° of glenohumeral abduction in the scapular plane under 4 conditions: (1) intact, (2) IASRCT, (3) combined LDTM transfer, and (4) isolated LD transfer. The superior and anteroinferior translation and subacromial contact pressure were measured. The effects of 3 different LD and LDTM muscle loading conditions were investigated to determine the effectiveness of the muscle transfer conditions. A linear mixed effect model was used for statistical analysis, followed by a Tukey post hoc test. IASRCTs significantly increased superior translation, anteroinferior translation, and subacromial peak contact pressure. Combined LDTM transfer significantly decreased superior and anteroinferior translation compared with IASRCTs in all positions and muscle loadings. Isolated LD transfer did not significantly decrease superior (P>.115) and anteroinferior translation (P>.151) compared to IASRCT at any abduction and muscle loads except superior translation at 60° abduction and 90° of external rotation (ER) (P<.036). LDTM transfer also significantly decreased peak contact pressure from the IASRCT condition at every abduction angle (P<.046). However, isolated LD transfer significantly decreased subacromial peak contact pressure only at 30° abduction and 0° and 30° of ER with triple loading (P<.048), as well as at 60° abduction and 90° of ER (P<.003). Combined LDTM transfer decreased superior translation, anteroinferior translation, and subacromial contact pressure compared with the IASRCT condition. Isolated LD transfer did not improve glenohumeral translation and subacromial contact pressure. Combined LDTM transfer may be a more reliable treatment option than isolated LD transfer in patients with an IASRCT.

Allograft-enhanced latissimus dorsi transfer is better than the conventional technique for irreparable posterosuperior rotator cuff tears. A retrospective matched cohort.

Latissimus dorsi tendon (LDT) transfer (LDTT) to the greater tuberosity to treat irreparable posterosuperior rotator cuff tears (RCTs) in young active patients has been shown to have up to 36% of clinical failures, most of them happening because of either deltoid origin disruption or post-operative transfer rupture from the greater tuberosity. In an attempt to simultaneously prevent both complications, a modified technique includes the following adaptations to the original technique: reinforcement and augmentation of the LDT with a tendinous allograft, enabling the use of a single deltopectoral approach. The aim of this study is to compare mid-term outcomes of the traditional LDTT technique with this modified transfer. Retrospective cohort study comparing two groups who underwent either the traditional (group 1; n = 19) or the modified technique (group 2; n = 27). Group homogenization was assured by statistical comparison of 24 baseline independent variables. The outcome variables were the gains to active shoulder range of motions (ROM) and UCLA scores (and all its subscores, independently), at a minimum follow-up of two years. A p value < .05 was considered to be statistically significant. At a mean follow-up of 25months, both groups have shown improvements to most variables. However, group two (modified technique) achieved greater improvements to UCLA score (p = .009), active external rotation (p = .006) and internal rotation (p = .008). At mid-term follow-up, improvements to outcomes of the modified (single approach, allograft-enhanced) latissimus dorsi transfer were greater than those of the original technique.

Options in Tendon Transfers for Anterior-Superior Rotator Cuff Tears: Review

Background. Irreparable anterior-superior rotator cuff tears can cause significant shoulder dysfunction due to the failure of normal biomechanics of the joint, because of the loss of compressive effect of the rotator cuff on the humeral head. Muscle-tendon transfers are an alternative to standard surgical treatment options: debridement of injured tendons, arthroscopic anchor suture, and reverse shoulder arthroplasty. Currently, several options of muscle-tendon transfers are described in the foreign literature, and there is an active discussion over the results of the already proposed techniques, and their improvements, while these techniques are practically not covered in the domestic literature.&#x0D; The aim to describe modern surgical technique options of the muscle-tendon transfers for the treatment of patients with anterior-superior rotator cuff tears based on a review of foreign literature sources.&#x0D; Methods. The search for publications from 1988 to 2022 was carried out in the PubMed/MEDLINE and Google Scholar databases.&#x0D; Results. Nowadays, the most common muscle-tendon transfers options for patients with anterior-superior rotator cuff tears are the sternocostal portion of the of pectoralis major tendon transfer and the latissimus dorsi tendon transfer. A review of foreign literature showed that muscle-tendon transfers are a well-described alternative to standard methods of treating profile patients with a predictable result.&#x0D; Conclusion. Currently, there is no consensus on clear indications for certain types of muscle-tendon transfers in case of anterior-superior rotator cuff tears, there is a lack of data on long-term results. This determines the need of study of the long-term clinical results of use of these methods and develop an algorithm for choosing the tactics of surgical treatment of relevant patients.

Comparing the Results of Latissimus Dorsi Versus Teres Major Transfer in Children With Obstetric Brachial Plexus Injury and Residual Shoulder Sequelae.

Obstetric brachial plexus injury (OBPI) remains a fairly common problem in newborns despite the improved obstetric care. Children who do not show complete recovery often present with residual shoulder deformity of limited external rotation and abduction. Secondary interventions in the form of tendon transfer and soft tissue release are aimed at correcting the implicated muscular imbalance to restore shoulder function. The aim of this work was to compare the results of latissimus dorsi versus teres major tendon transfer in patients with OBPI with limited shoulder external rotation. This study included 40 patients admitted to El Hadara University Hospital with OBPI and limited shoulder abduction and external rotation aged between 1.5 and 4 years. Half of the patients had a latissimus dorsi transfer, and the other half, a teres major one. Children with limited preoperative passive external rotation in both groups required a subscapularis slide. Patients were evaluated preoperatively, at 6 months, and 12 months postoperatively using the Gilbert scale. Teres major tendon transfer showed better results in restoring limited shoulder abduction and external rotation than latissimus dorsi transfer. Limited shoulder internal rotation was the main complication occurring postoperatively. Loss of the last degree of internal rotation occurred in most patients who had subscapularis slide. Most patients regained functional midline abilities with physiotherapy and required no further interventions. Isolated teres major transfer has shown better results in improving the range of external rotation and abduction compared with isolated latissimus dorsi tendon transfer. Age of the patients did not affect the overall final improvement in shoulder range of motion. Limited internal rotation is the main complication postoperatively, which was prevalent in patients who required a subscapularis slide but was not statistically significant.

Latissimus dorsi and teres major tendon transfer for irreparable anterosuperior rotator cuff tear improves kinematics and internal rotation compared to latissimus dorsi tendon transfer.

Latissimus dorsi and teres major (LDTM) tendon transfer has demonstrated better clinical outcomes compared to Latissimus dorsi (LD) transfer for irreparable anterosuperior cuff (subscapularis/supraspinatus) tears; however, the biomechanical effects of these procedures are unknown. Therefore, the objective of this study was to compare kinematics and internal rotation of LDTM transfer to LD transfer for anterosuperior cuff tear. Eight cadaveric shoulders were tested in four conditions; (1) intact, (2) anterosuperior rotator cuff tear, (3) LDTM transfer, and (4) LD transfer. Glenohumeral kinematics and internal rotation at 0°, 30°, and 60° of glenohumeral abduction in the scapular plane were measured. Muscle loading was applied based on physiological cross-sectional area ratios with three muscle loading conditions to simulate potentially increased tension due to the advanced insertion site of the transferred tendons. The anterosuperior rotator cuff tear leads to a significant superior shift of the humeral head compared to intact at 0° and 30° abduction (p < 0.039). Both the LDTM (p < 0.047) and LD transfers (p < 0.032)significantly shifted the humeral head inferiorly compared to the tear condition.; however, the LDTM transfer shifted the head in the anteroinferior direction compared to the LD transfer at 60° abduction and 30° ER (p < 0.045). Both LDTM and LD transfer significantly increased internal resting rotation (p < 0.008) and maximum internal rotation (p < 0.008) compared to anterosuperior rotator cuff tear and intact at 30° and 60° abduction. LDTM transfer resulted in a significant internal resting rotation compared with the LD transfer at 30° abduction with double muscle loading (p = 0.02). At 0° abduction, the LDTM transfer (p < 0.027) significantly increased maximum internal rotation compared to anterosuperior rotator cuff tear and intact. Although both LDTM and LD tendon transfer improved the abnormal humeral head apex position and internal rotation compared with the tear condition, the LDTM transfer was biomechanically superior to the LD transfer in a cadaveric model.

Tendon Transfers in Rotator Cuff Deficiency

Massive irreparable rotator cuff tears (MIRCT) is a difficult clinical problem to treat in young, active individuals with minimal arthritis. Tendon transfers allow for donation of muscle units that can power the shoulder and restore kinematics. Posterosuperior rotator cuff deficiency can be treated with either a latissimus dorsi tendon or lower trapezius tendon transfer. The authors preferred method for treating irreparable supraspinatus and infraspinatus tears is with an arthroscopic assisted lower trapezius tendon transfer. The advantage of the lower trapezius tendon is that its vector is directly in line with the infraspinatus tendon allowing for better external rotation and abduction moment arms. The tendon is harvested from the spine of the scapula and augmented with an Achilles tendon allograft for length which is then secured at the footprint of the rotator cuff. Anterosuperior rotator cuff deficiency can be treated with a pectoralis major tendon or anterior latissimus tendon transfer. For subscapularis deficiency, our preferred method is an open versus arthroscopic latissimus tendon transfer. The tendon is harvested in the posterior axilla and augmented with an Achilles tendon allograft at the tendon interface to provide bulk. The tendon is passed arthroscopically to the anterior humerus and secured at the lesser tuberosity. Tendon transfers are a safe, reliable and reproducible technique when treating MIRCTs.